ISSN 1941-5923 © Am J Case Rep, 2017; 18: 194-197 DOI: 10.12659/AJCR.902297
Progressive Ischemic Stroke due to Thyroid Storm-Associated Cerebral Venous Thrombosis
Received: 2016.11.09 Accepted: 2016.12.07 Published: 2017.02.23
Authors’ Contribution: Study Design A Data Collection B Statistical Analysis C Data Interpretation D Manuscript Preparation E Literature Search F Funds Collection G
DEF 1 DEF 1 E 2 E 3 E 4 E 5
E 5
E 6
Natsumi Tanabe Eiji Hiraoka Masataka Hoshino Gautam A. Deshpande Kana Sawada Yasuhiro Norisue Jumpei Tsukuda Toshihiko Suzuki
1 Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan 2 Department of Internal Medicine, Funabashi General Hospital, Funabashi, Chiba, Japan 3 Department of Internal Medicine, University of Hawaii, Honolulu, HI, U.S.A. 4 Department of Neurosurgery, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan 5 Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan 6 Department of Nephrology, Endocrinology, and Diabetes, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan
This case was previously presented at the Society of General Internal Medicine (SGIM) Annual Meeting 2016 and the abstract was published in the Journal of General Internal Medicine
Eiji Hiraoka, e-mail: [email protected] None declared
Corresponding Author: Conflict of interest:
Patient: Female, 49 Final Diagnosis: Cerebral venous thrombosis Symptoms: Altered mental state • weakness in limbs Medication: — Clinical Procedure: — Specialty: Endocrinology and Metabolic
Objective: Background:
Care Report:
Conclusions:
MeSH Keywords:
Full-text PDF:
Rare co-existance of disease or pathology Cerebral venous thrombosis (CVT) is a rare but fatal complication of hyperthyroidism that is induced by the hypercoagulable state of thyrotoxicosis. Although it is frequently difficult to diagnose CVT promptly, it is important to consider it in the differential diagnosis when a hyperthyroid patient presents with atypical neurologic symptoms. A 49-year-old Japanese female with unremarkable medical history came in with thyroid storm and multiple progressive ischemic stroke identified at another hospital. Treatment for thyroid storm with beta-blocker, glucocorticoid, and potassium iodide-iodine was started and MR venography was performed on hospital day 3 for further evaluation of her progressive ischemic stroke. The MRI showed CVT, and anticoagulation therapy, in addition to the anti-thyroid agents, was initiated. The patient’s thyroid function was successfully stabilized by hospital day 10 and further progression of CVT was prevented. Physicians should consider CVT when a patient presents with atypical course of stroke or with atypical MRI findings such as high intensity area in apparent diffusion coefficient (ADC) mapping. Not only is an early diagnosis and initiation of anticoagulation important, but identifying and treating the underlying disease is essential to avoid the progression of CVT. Early Diagnosis • Intracranial Thrombosis • Thrombophilia • Thyroid Crisis • Venous Thrombosis http://www.amjcaserep.com/abstract/index/idArt/902297
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This work is licensed under Creative Common Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)
Tanabe N. et al.: Cerebral venous thrombosis due to thyroid storm © Am J Case Rep, 2017; 18: 194-197
Background Cerebral venous thrombosis (CVT) is a rare but potentially fatal cerebrovascular complication of hyperthyroidism that is induced by the hypercoagulable state of thyrotoxicosis [1–6]. The clinical manifestation of CVT differs greatly between cases and this makes the diagnosis difficult for clinicians [7]. It is important to include CVT in the differential diagnosis and make further investigation when a hyperthyroid patient appears with atypical neurologic symptoms and findings on images [7,8]. To avoid the progression of thrombosis, it is necessary to make early diagnosis and initiate anticoagulation as well as provide treatment for the underlying disease. Here, we describe a unique patient who presented with hyperthyroid storm and progressive ischemic stroke caused by CVT.
Case Report A 49-year-old Japanese female with an unremarkable medical history presented to an outside clinic with a one-month history of headaches, palpitations, diaphoresis, and weight loss. Her family history was not remarkable and the patient denied any history of tobacco smoking, heavy alcohol consumption, or substance abuse. Subsequent laboratory investigations revealed TSH of
Progressive Ischemic Stroke due to Thyroid Storm-Associated Cerebral Venous Thrombosis
Received: 2016.11.09 Accepted: 2016.12.07 Published: 2017.02.23
Authors’ Contribution: Study Design A Data Collection B Statistical Analysis C Data Interpretation D Manuscript Preparation E Literature Search F Funds Collection G
DEF 1 DEF 1 E 2 E 3 E 4 E 5
E 5
E 6
Natsumi Tanabe Eiji Hiraoka Masataka Hoshino Gautam A. Deshpande Kana Sawada Yasuhiro Norisue Jumpei Tsukuda Toshihiko Suzuki
1 Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan 2 Department of Internal Medicine, Funabashi General Hospital, Funabashi, Chiba, Japan 3 Department of Internal Medicine, University of Hawaii, Honolulu, HI, U.S.A. 4 Department of Neurosurgery, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan 5 Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan 6 Department of Nephrology, Endocrinology, and Diabetes, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan
This case was previously presented at the Society of General Internal Medicine (SGIM) Annual Meeting 2016 and the abstract was published in the Journal of General Internal Medicine
Eiji Hiraoka, e-mail: [email protected] None declared
Corresponding Author: Conflict of interest:
Patient: Female, 49 Final Diagnosis: Cerebral venous thrombosis Symptoms: Altered mental state • weakness in limbs Medication: — Clinical Procedure: — Specialty: Endocrinology and Metabolic
Objective: Background:
Care Report:
Conclusions:
MeSH Keywords:
Full-text PDF:
Rare co-existance of disease or pathology Cerebral venous thrombosis (CVT) is a rare but fatal complication of hyperthyroidism that is induced by the hypercoagulable state of thyrotoxicosis. Although it is frequently difficult to diagnose CVT promptly, it is important to consider it in the differential diagnosis when a hyperthyroid patient presents with atypical neurologic symptoms. A 49-year-old Japanese female with unremarkable medical history came in with thyroid storm and multiple progressive ischemic stroke identified at another hospital. Treatment for thyroid storm with beta-blocker, glucocorticoid, and potassium iodide-iodine was started and MR venography was performed on hospital day 3 for further evaluation of her progressive ischemic stroke. The MRI showed CVT, and anticoagulation therapy, in addition to the anti-thyroid agents, was initiated. The patient’s thyroid function was successfully stabilized by hospital day 10 and further progression of CVT was prevented. Physicians should consider CVT when a patient presents with atypical course of stroke or with atypical MRI findings such as high intensity area in apparent diffusion coefficient (ADC) mapping. Not only is an early diagnosis and initiation of anticoagulation important, but identifying and treating the underlying disease is essential to avoid the progression of CVT. Early Diagnosis • Intracranial Thrombosis • Thrombophilia • Thyroid Crisis • Venous Thrombosis http://www.amjcaserep.com/abstract/index/idArt/902297
1454
194
—
1
27
This work is licensed under Creative Common Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)
Tanabe N. et al.: Cerebral venous thrombosis due to thyroid storm © Am J Case Rep, 2017; 18: 194-197
Background Cerebral venous thrombosis (CVT) is a rare but potentially fatal cerebrovascular complication of hyperthyroidism that is induced by the hypercoagulable state of thyrotoxicosis [1–6]. The clinical manifestation of CVT differs greatly between cases and this makes the diagnosis difficult for clinicians [7]. It is important to include CVT in the differential diagnosis and make further investigation when a hyperthyroid patient appears with atypical neurologic symptoms and findings on images [7,8]. To avoid the progression of thrombosis, it is necessary to make early diagnosis and initiate anticoagulation as well as provide treatment for the underlying disease. Here, we describe a unique patient who presented with hyperthyroid storm and progressive ischemic stroke caused by CVT.
Case Report A 49-year-old Japanese female with an unremarkable medical history presented to an outside clinic with a one-month history of headaches, palpitations, diaphoresis, and weight loss. Her family history was not remarkable and the patient denied any history of tobacco smoking, heavy alcohol consumption, or substance abuse. Subsequent laboratory investigations revealed TSH of
